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Background: Abnormally enlarged, tortuous and dysplastic penile venous vasculature (phlebectasia) are rare in children. The prevalence of this anomaly and its possible etiologic correlation with circumcision is examined in this study.

Patients and methods: This is a prospective comparative cohort study of 830 children, aged 6 months to 12 years, enrolled between June 2021 and December 2023. Among them, 420 were circumcised (group A) and 410 were intact (group B). All of them were physically examined and investigated with Doppler ultrasound for any abnormality of the penile venous vasculature. The two groups were compared for any difference in the incidence of different anomalies of the penile veins and penile deviation or chordee. Data were analyzed by Mann–Whitney U-test and a P-value less than 0.05 was considered significant.

Results: Phlebectasia (21/420) and phlebothrombosis (3/420) were more frequently seen in the circumcised group, but they were rare in the intact group (2/410). These venous abnormalities were commonly seen in the dorsum of the penis (15/24). In circumcised patients, the phlebectasia was associated with penile deviation to the left side in 13 cases and a ventral penile chordee in 1 case. But, in uncircumcised children, the prominent dorsal penile vein was not associated with any chordee. An associated dilation of the deep dorsal penile vein was confirmed in 15 of the 24 cases.

Conclusion: Circumcision wound and the subsequent scar may increase the incidence of abnormal penile venous vasculature which is commonly associated with penile deviation.

Abstract
Background: Hypospadias is the most common congenital abnormality of the penis. Its incidence is on the rise; however, its reconstructive repair remains a huge challenge. We reviewed our experience with an aim to expand our understanding and modify the treatment protocols.
Patients and Methods: This is a retrospective evaluation of all consecutive cases of hypospadias repaired at a Nigerian Teaching Hospital between January 2013 and June 2018. Data on demography, presentations, type of anomaly, repair techniques and outcome were extracted from case records and analyzed.

Results: A total of 64 boys had primary repair for hypospadias. The median age at presentation and at repair was 17 and 28.5 months respectively. At presentation, 32% had already been circumcised and 71% of them had been done by nurses. The most commonly associated anomaly was inguinal hernias in 3 (5%) and chordee in 39(61%). The location of the meatus was glanular in 2 (3%), coronal in 20 (31%), distal penile in 17 (27%), mid-penile in 6 (9%), proximal penile in 5 (8%), penoscrotal in 7 (11%), interscrotal in 2 (3%) and perineal in 5 (8%). Case volume doubled in two successive years with a peak of 15 per year. Techniques of repair were tubularized incised plate urethroplasty (TIPU) in 51 (80%), Koyanagi in 7 (11%), Thiersch-Duplay in 4 (6%) and staged repair in 2 (3%). Urethrocutaneous fistulae occurred in 16 (25%); however, in 12 (75%) fistula healed spontaneously. There was a drop in fistula rate from 40% in 2015 to 6.3% in 2018.

Conclusion: The incidence of hypospadias in our center is on the increase. In proximal variants staged repairs or Koyanagi technique have better outcomes than TIPU. Sustained practice and modification of techniques reduce complications.

In this issue (July-Sep 2024) of the Pediatric Surgery in Tropics, Dr. Ugwu et.al have reported their experience with hypospadias in Nigerian children.(1) It is commendable that they have improved the results of their hypospadias repairs over a few years. The authors have not mentioned certain details such as the width of the urethral plate, the width of the glans and the degree of chordee following penile degloving. Tubularized incised plate urethroplasty (TIPU) was employed in 51 of the 64 patients, including the 5 out of 7 penoscrotal hypospadias. TIPU is a versatile, reliable, cosmetic and functionally successful surgical method mainly used in distal hypospadias; but in recent times it is also used in some proximal varieties. Its main complications are urethro-cutaneous fistula, urethral meatus stenosis, glans dehiscence and urethral meatus dehiscence that the authors have noted in their series too. The urethro-cutaneous fistula and meatal stenosis rates have been reported as high as 12% and 15% respectively in a recent article.(2) Narrow urethral plate, flat glandular groove and small glans were found to be significantly associated with higher complication rates in TIPU. Further, Snodgrass advocated that a small glans (usually associated with proximal hypospadias) measuring less than 14 mm in width is not ideal for TIPU.(3) Some authors believe that TIPU should not be used if the urethral plate width (UPW) is less than 8 mm.(4,5), though Snodgrass denies the significance of this parameter.(6) Others believe that the functional outcome rather than cosmetic appearance of hypospadias repair is predicted by the UPW.(7)

Mathieu’s urethroplasty is a good option for distal hypospadias with a narrow urethral plate and is recommended.(8) A hybrid technique of Mathieu’s urethroplasty incorporated with TIPU is also in vogue for distal penile hypospadias with small glans and shallow urethral plate.(9)

Another point of controversy could be the use of a single-stage TIPU in patients with proximal hypospadias with significant chordee. There is no mention in the paper about the use of artificial erection test or the use of dorsal plication when single-stage urethroplasty was employed in such patients. Staged procedures should be more liberally performed in such cases as they tend to have better cosmetic and functional results.(10)

Abstract
A 5-year-old girl was admitted with signs of peritonitis following gunshot injury of the abdomen. At laparotomy, a perforation of 1.5 cm diameter on the greater curvature of stomach was noted. Intraoperatively the projectile could not be located and hence gastrorrhaphy was performed. Postoperatively, a plain abdominal radiograph revealed the presence of a projectile in the abdomen. The patient resumed intestinal motility with diarrhea on the postoperative day-4. The bullet was spontaneously expelled during defecation on the postoperative day-7 and the diarrhea resolved on the postoperative day-11. Gastrointestinal bullet embolism with spontaneous expulsion of the bullet is a very rare phenomenon.

Abstract
Cholelithiasis is an uncommon pathology in the pediatric age group, with an incidence of 0.13-1.9%. The standard of treatment is laparoscopic cholecystectomy (LC). Open cholecystectomy (OC) has been rarely performed nowadays. We report a 5-year-old boy who underwent OC for gallstones and had sustained bile duct injury (BDI), which was missed intra-operatively. The child presented with fever, abdominal collection, and sepsis. We discuss the management of a patient with BDI along with the review of pertinent literature.

Abstract
Meconium periorchitis (MPO) is an uncommon disease secondary to meconium peritonitis. We report two infants with MPO one of whom presented with acute hydrocele while the other was asymptomatic (incidental diagnosis). Both of them did not have any other associated malformations. Abdomino-pelvic plain X-ray and ultrasound was useful in confirming the diagnosis. Both the patients were managed without surgery. There were no complications at 12-months and 2-months of follow-up respectively.

Abstract
Congenital para-urethral cyst is a rare pathology especially in male infants. We report a large cyst in a 40-days-old infant who was referred suspecting a scrotal tumor. This scrotal mass was present since birth and progressively increased in size to reach 15 x 10 cm. It was associated with dysuria. Attempts at urethral probing were unsuccessful and needle aspiration of the mass yielded a clear liquid. Perineal ultrasound showed a cyst with solid components. The cyst was excised en-block separating its attachment to the prostatic urethra. The postoperative course and short term follow-up were uneventful. Histopathology confirmed it as a benign epidermoid cyst.

Abstract
Bladder and urethral agenesis are among the rarest congenital anomalies, and to our knowledge, only 27 cases have been reported in English literature until now. The authors treated two such cases in the last one year. The first case was diagnosed at 2 months of age, and the second case at 10 months of age. Both were females. In The first case ureterosigmoidostomy was done at 1 year of age. The second case had features of chronic kidney disease due to a stenosed ectopic ureter. Therefore, diverting cutaneous ureterostomy was done. Bladder and urethral agenesis are associated with other congenital anomalies, mostly with upper urinary tract anomalies. To prevent diagnostic delay and to reduce mortality cum mortality by early management, awareness of this rare condition is essential

Abstract
Non-tender enlargement of the spleen is common in malaria; but splenic infarction is a rare complication. It is frequently masked under acute clinical condition. Until now only a few cases of splenic infarction in patients with falciparum malaria have been published. We describe a 10-year-old girl who presented with signs and symptoms of malaria along with tender massive splenomegaly and worsening pain in the left upper quadrant of the abdomen which was not responding to medications. Contrast enhanced CT scan of abdomen revealed massive splenic infarction. The patient underwent laparotomy and total splenectomy. Her postoperative course was uneventful.

Mr. Stephen Wyles was born with esophageal atresia. He is running a voluntary patient support group (Birth-defect.org) that helps children born with esophageal atresia in resource poor tropical countries. In this article he shares his perspectives and ordeals of a child born with esophageal atresia.

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